2,427 results
0y · Male·hypoxia due to intrauterine pneumonia and haemorrhage with uterine rupture in a …
A neonate died shortly after birth from hypoxia due to intrauterine pneumonia, haemorrhage and uterine rupture following prolonged rupture of membranes during a planned vaginal birth after caesarean (VBAC). The mother at…
29y · Male·Florid myocarditis
Samuel Seeto, a previously healthy 29-year-old, died from florid myocarditis after a general practitioner failed to detect his cardiac condition. He presented on 5 December 2015 with a 3-day history of fatigue, feeling c…
45y · Male·gunshot wound to the chest
A man with a long history of depression, suicide attempts, and previous violent behaviour died when shot by police during an arrest for domestic violence. His partner had repeatedly warned police that he threatened to ma…
34y · Male·drowning
A 34-year-old man with schizoaffective disorder drowned after attempting to surf in dangerous conditions on 31 December 2015. He had been under community mental health care with fragmented coordination between public and…
72y · Male·Bilateral pneumothoraces and pneumoperitoneum due to insufflation of the bladder…
Stephen Herczeg, a 72-year-old patient with COPD and urinary tract infection, died from bilateral pneumothoraces and pneumoperitoneum caused by insufflation of his bladder with oxygen. The oxygen supply tubing was someho…
27y · Female·hanging, self-inflicted with intention of taking own life
A 27-year-old Aboriginal woman with borderline personality disorder died by suicide within hours of discharge from an emergency department. She presented after her GP attempted to schedule her under the Mental Health Act…
76y · Female·Acute renal failure due to dehydration due to upper gastrointestinal bleed
A 76-year-old woman with chronic pain was admitted to a small rural hospital on 1 April 2015 with haematemesis secondary to NSAID use. Blood tests were ordered on admission but not transported to the district hospital fo…
16y · Female·Mixed drug toxicity
Maria Liordos, a 16-year-old in state care with complex trauma, substance abuse, mental health issues and high-risk behaviours, died from mixed drug toxicity. The coroner identified significant failures in supervision an…
81y · Female·left haemothorax and mediastinal haemorrhage from the insertion site of the perm…
An 81-year-old woman died from haemothorax and mediastinal haemorrhage following pacemaker insertion for sick sinus syndrome. Multiple venous punctures during the procedure caused vascular injury. Critical clinical lesso…
33y · Female·blunt impact injuries to neck and chest
A 33-year-old woman with depression, anxiety, and emerging psychotic symptoms presented to the ED on two consecutive days (26 and 28 October 2013). Following the first presentation, she was assessed by a psychiatric nurs…
78y · Male·metastatic malignancy (unknown primary) with contributing right-sided heart fail…
Leonard Edward Dodson, aged 78, died in custody from metastatic liver cancer (unknown primary) with contributing right-sided heart failure. He had prostate cancer diagnosed in 2010 via elevated PSA (20ng/ml) but was not …
41y · Female·mixed drug and alcohol toxicity
Karen Louise Richards, 41 years old, died from mixed drug and alcohol toxicity on 11 January 2014. She had consumed heroin (evidenced by 6-MAM metabolite), alcohol, benzodiazepines, and other prescription medications. He…
21y · Female·mixed heroin and alprazolam toxicity
Paigh Bartholomew, 21-year-old Aboriginal woman, died from mixed heroin and alprazolam toxicity in a minimum-security correctional centre following systemic failures. She had been placed in a minimum-security facility de…
22y · Female·compression of the neck consistent with hanging
22-year-old Deborah McKenzie, an Aboriginal woman, died by hanging on 13 March 2013 after a complex sequence of failures in mental health care and police procedures. She had reported her partner Shane Woods to police for…
36y · Female·Complications of pneumonia and pulmonary emphysema with bullae formation; respir…
A 36-year-old woman with congenital chest wall abnormality, scoliosis, and difficult intubation history presented to a rural hospital with community-acquired pneumonia and sepsis. She had multiple 'red flag' indicators o…
73y · Male·Acute intracranial haemorrhage, due to or as a consequence of coagulopathy, due …
Mr Stimpson, a 73-year-old man, died from massive intracerebral haemorrhage secondary to coagulopathy caused by inadvertent double administration of anticoagulants (Clexane and Xarelto). He developed bilateral pulmonary …
49y · Male·bronchopneumonia
49-year-old male seaman died of bronchopneumonia with secondary pericarditis on a cargo vessel 30 nautical miles off Port Hedland. He developed acute abdominal pain and vomiting on 29 September 2012 and deteriorated rapi…
40y · Male·multiple injuries sustained from fall from bathroom window
Warren Maguire, aged 40, died from multiple injuries sustained after exiting a bathroom window at his unit. The coroner found he was alive for 30-45 minutes after the fall. A concerned neighbour called police at 12:23 AM…
41y · Female·Left middle cerebral artery territory ischaemic stroke
A 41-year-old registered nurse presented to the Emergency Department with altered consciousness on 28 May 2015. She was initially assessed as having a possible medication overdose rather than acute stroke, despite later …
79y · Male·Head and neck injuries from blunt force trauma
Mr Risto Pedevski, a 79-year-old man, was fatally assaulted by his son George in November 2014 during a dispute over a gas hot water system. George had a long-standing diagnosis of schizophreniform disorder and paranoid …
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